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Primary Retinal Detachment

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168<br />

Inadequate Training<br />

Vitrectomy is being increasingly employed for primary retinal detachments<br />

because the number of doctors trained to do vitrectomy<br />

has markedly increased in the past decade, as have the indications<br />

for vitrectomy. In addition to the original indications, traction detachment<br />

in the diabetic eye and PVR after failed retinal surgery,<br />

vitrectomy is done for macular holes, macular puckers, dropped<br />

lens and particles, to clear vitreous hemorrhage, and, more recently,<br />

to dissect subretinal proliferative lesions in the macula. The indications<br />

keep expanding. <strong>Retinal</strong> detachment can be a relatively<br />

infrequent indication for operation on a busy retinal service and of<br />

secondary interest. As a result, training for the treatment of retinal<br />

detachment may be limited. There are few opportunities outside of<br />

the fellowship to learn about buckling. <strong>Retinal</strong> programs rarely<br />

include papers on the subject; it has all been said. Except for<br />

William Mieler’s short course at the Academy and Ingrid Kreissig’s<br />

<strong>Retinal</strong> <strong>Detachment</strong> Courses at various national and international<br />

meetings, there are no workshops on the art of scleral buckling.<br />

As a consequence, the coming generation of retinal surgeons may<br />

not be very skillful at performing a scleral buckle. In another<br />

decade, it is possible that the buckling operation will have become<br />

a lost art.<br />

Market Forces<br />

8 Systematic Review of Efficacy and Safety of Surgery<br />

Preparation for a segmental buckle operation can require much<br />

study time, frequently hours and sometimes days. A decade ago, if<br />

the senior author (HL) could not find a break that promised a 90%<br />

prognosis after an hour’s study, he would patch both eyes, put the<br />

patient at rest, and re-study the eye the next day. Most detachments<br />

change with ocular rest, and the change is informative. Today, the<br />

insurance companies and Medicare do not allow for an extra day,<br />

nor is there payment for study time. It is more expedient to do a

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